Spring 2022 C.N.A Requirements for Clinical
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Spring 2022 C.N.A Requirements for Clinical
1. Negative PPD (given later than December 17, 2021) or negative chest x-ray if you
have a history of a positive PPD (completed later than December 17, 2021).
2. Positive rubella titer or proof of two doses of MMR or rubella vaccine.
3. Positive mumps titer or proof of two doses of MMR or mumps vaccine
4. Positive measles titer or proof of two doses of MMR or measles vaccine
5. Positive varicella titer or proof of two doses of varicella vaccine.
6. Positive hepatitis B titer or proof of three doses of hepatitis B vaccine.
7. Proof of tetanus/diphtheria (Td) within the last ten years.
8. Flu vaccination for current year (August 2021 – April 2022)
9. Proof of completed Covid 19 vaccination
10. Ten panel-drug plus alcohol screening (see attached drug testing list/info). It is
mandatory that you obtain this screening from Castle Branch (information is located
on the Gavilan website http://www.gavilan.edu/academic/ah/CNA.php for a cost of
$39.00.
11. Live-Scan submission must be submitted on first day of class which will be January
18, 2022 (for Tuesday clinical group) or January 19, 2022 (for Wednesday clinical
group) with receipt to instructor. CDPH clearance will be required to receive
certification as a Certified Nursing Assistant.
NOTE: You must complete all three (3) live scan forms included in this packet and take
to your preferred live scan location. Follow the included live scan sample when
completing the forms.
ALL HEALTH STATEMENTS, DRUG SCREENING, PPD TEST, & VACCINE INFORMATION
MUST BE COMPLETED BY January 27, 2022.
OR YOU WILL NOT BE ABLE TO ATTEND CLINICAL THEREFORE JEOPORDIZING YOU
COMPLETING THE PROGRAM.
NOTE: CDPH regulations require that a Health and Physical and TB test be completed for
all healthcare workers 90 days prior to starting clinical. All other requirements are policy
and procedures enacted by hospitals/facilities in order for students to attend clinical.
1STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 PAGE 1 of 2
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE
Print Form Reset Form
Applicant Submission
ORI (Code assigned by DOJ) Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
City State ZIP Code Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias) Last First Suffix
Sex Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country) Social Security Number Number
(Other Identification Number)
Home
Address Street Address or P.O. Box City State ZIP Code
Your Number: Level of Service: DOJ FBI
OCA Number (Agency Identifying Number) (If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencySTATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 PAGE 1 of 2
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE Print Form Reset Form
Applicant Submission
ORI (Code assigned by DOJ) Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
City State ZIP Code Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias) Last First Suffix
Sex Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country) Social Security Number Number
(Other Identification Number)
Home
Address Street Address or P.O. Box City State ZIP Code
Your Number: Level of Service: DOJ FBI
OCA Number (Agency Identifying Number) (If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencySTATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 PAGE 1 of 2
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE Print Form Reset Form
Applicant Submission
ORI (Code assigned by DOJ) Authorized Applicant Type
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
City State ZIP Code Contact Telephone Number
Applicant Information:
Last Name First Name Middle Initial Suffix
Other Name
(AKA or Alias) Last First Suffix
Sex Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color Number
(Agency Billing Number)
Misc.
Place of Birth (State or Country) Social Security Number Number
(Other Identification Number)
Home
Address Street Address or P.O. Box City State ZIP Code
Your Number: Level of Service: DOJ FBI
OCA Number (Agency Identifying Number) (If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting AgencySTATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016 PAGE 2 of 2
(Rev. 05/2018)
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
∙ With other persons or agencies where necessary to perform their legal duties, and their use of
your information is compatible and complies with state law, such as for investigations or for
licensing, certification, or regulatory purposes;
∙ To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8016
(orig. 4/01; rev. 6/09)
SAMPLE FOR CERTIFICATION OF NURSE ASSISTANTS OR HOME HEALTH AIDES
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A1226 Certification
ORI (Code assigned by DOJ) Authorized Applicant Type
Certified Nurse Assistant (CNA) or Home Health Aide (HHA)
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
California Department of Public Health (CDPH) 03314
Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)
MS 3301, P.O. Box 997416 (Leave blank)
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
Sacramento CA 95899-7416 (Leave blank)
City State Zip Code Contact Telephone Number
Applicant Information:
Your last name Your first name & middle initial
Last Name First Name Middle Initial Suffix
Other Name Other last names known as Other first names known as
(AKA or Alias) Last First Name Suffix
(Check one)
Date of Birth Sex: D Male D Female California Driver's License Number
Date of Birth Driver's License Number
Height Weight Color Color Billing Not Applicable
Height Weight Eye Color Hair Color Number (Agency Billing Number)
Place of Birth "Social Security Number (Required by CDPH)
Misc. Your telephone number
Place of Birth (State or Country) Social Security Number Number (Other Identification Number)
Home Your mailing address
Address Street Address or P.O. Box City State Zip Code
Your Number: *Socia/ Security Number (Required by CDPH) Level of Service: [R] DOJ 0 FBI
OCA Number (Agency Identification Number)
If re-submission, list ATI number:
(Must provide proof of Rejection) Original ATI Number
Employer (Additional response for agencies specified by statute):
(Leave blank)
Employer Name Mail Code (five-digit code assigned by DOJ)
Street Address or P.O. Box
City State Zip Code Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSI□ ATI Number Amount Collected/Billed
BCIA 8016 (Rev 07111) SAMPLE
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
NOTE TO APPLICANT: *Please input your Social Security Number (SSN) where required. The submission of your SSN will allow results to
be transmitted from DOJ to CDPH accurately and timely. Failure to submit your SSN could cause delay in your certification.
2Recommended option for drug & alcohol screening:
Cost: $39.00
3HEALTH STATEMENT
TO BE COMPLETED BY STUDENT:
Name of Applicant: __________________________________________ Program: ______________________
Last Name First Name
Do you have any medical condition or disability which may limit your ability to perform the tasks and functions
of a healthcare worker? Yes No
If yes, what can be done to accommodate your disability? __________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________.
Students admitted to the program are required to complete immunizations or titers in accordance with agency
policies and CDC recommendations for healthcare personnel. Written proof must be on file.
TO BE COMPLETED BY EXAMINING PHYSICIAN/NURSE PRACTITIONER:
Please review the attached requirements for healthcare students. Complete this form and return to the
student in a sealed envelope.
Date of complete physical examination: ___________________________
Does the applicant have any medical condition or disability which may limit his/her ability to perform the tasks
and functions of a healthcare worker? Yes No
If yes, what can be done to accommodate his/her disability? _______________________________________
_____________________________________________________________________________
____________________________________________________________________________.
Upon review of the physical exam and lab results, I certify that this student is medically able to perform all
clinical activities without restrictions and that the student does not have a health condition that creates a
hazard to self or others.
MD/NP Signature _______________________________________ Date _____________________________
Print Name: __________________________________________________ License #: ___________________
Address: _________________________________________________________________________________
Phone number (_____) ____________________
4Physical Requirements for healthcare workers
The health and safety of the consumer of health care must be protected. The student must be able to perform the work required in the program without
limitation. The student will refrain from attending the clinical area if any condition would interfere with patient safety.
1. Standing / Walking - 75% to 95% of work day spent standing/walking on carpet, tile, linoleum, asphalt and cement while providing patient care.
2. Sitting - 5% to 25% of work day spent sitting while operating computers, answering the telephone, writing reports, reviewing computer printout,
charting, and gathering data.
3. Lifting - 10% to 15% of work day spent floor to knee, knee to waist, waist to waist and waist to shoulder level lifting while handling supplies,
handling IV bottles, using trays, charting patient information, assisting with positioning and transferring patients.
4. Carrying - Up to 65% of work day spent carrying at waist level miscellaneous patient supplies.
5. Pushing / Pulling - Up to 40% of work day spent pushing/pulling patient care equipment.
6. Climbing - Up to 25% of work day spent climbing stairs going to and from other departments, clinics, office, and homes.
7. Balancing - Up to 25%, see climbing.
8. Stooping / Kneeling - Up to 10% of work day spent stooping/kneeling while retrieving medications from refrigerator, loading tray from supplies
on lower shelves, using lower shelves of cart, stocking shelves, and retrieving items from bedside stands, bathrooms, storerooms, and
providing patient care.
9. Bending - Up to 20% of work day spent bending at the waist while performing patient checks, gathering supplies, assisting with patient
positioning, priming IV tubing, adjusting patient beds, adjusting exam table, tying and untying patient restraints, bathing patients, emptying
tubes, and retrieving patient belongings.
10. Crawling - Up to 2% retrieving patient belongings.
11. Reaching / Stretching - Up to 35% of work day spent reaching/stretching while hanging IV bottles, checking IV solutions, gathering supplies,
operating the computer, disposing of dirty needles in containers, plugging in tubing over bed, assisting with patient positioning, connecting
equipment and retrieving patient files.
12. Handling - Up to 90% hand-wrist movement, hand-eye coordination, simple firm grasping required.
13. Fingering - Up to 90% fine and gross finger dexterity required.
14. Feeling - Up to 90% normal tactile feeling required. Sensitivity to heat, cold, pain, pressure, etc.
15. Twisting - Up to 15% of work day spent twisting at the waist while gathering supplies and equipment, operating equipment, and
performing patient care.
16. Talking - Up to 95% average ability required. Fluent in English. Ability to communicate with wide variety of people and styles, ability to be
easily understood.
17. Hearing - Up to 95% ability to hear and interpret many people and correctly interpret what is heard; i.e., physicians’ orders whether verbal or
over telephone, patient complaints, physical assessment, fire and equipment alarms, patient call bells, paging system, etc.
18. Seeing - Up to 95% acute visual skills necessary to detect signs and symptoms, coloring and body language of patients, color of wounds and
drainage, infiltrated IV sites, and possible infections anywhere, interpret written work accurately, read characters and identify colors.
19. Smelling - Up to 95% acute olfactory skills to detect signs and symptoms of infection, bleeding, acidosis, smoke, fire, noxious chemicals,
and/or gasses.
Essential Cognitive Learning Skills
1. Possess critical thinking abilities sufficient for clinical judgment: the ability to assess patient status and make appropriate clinical decisions
regarding course of action within given time constraints.
2. Effectively synthesize clinical data from a variety of sources including written, verbal, and observational (assessment).
3. Prioritize nursing care for needs of multiple patients simultaneously.
4. Demonstrate independence in reasoning and decision making based on written, verbal, and observational data.
5. Solve practical problems and deal with a variety of variables in situations where only limited standardizations exist.
6. Perform mathematical calculations for medication preparation and administration.
Essential Communication Skills
1. Communicate clearly, verbally, nonverbally and in writing, demonstrating appropriate grammar, vocabulary, and word usage.
2. Interact effectively on an interpersonal levels with clients, families, and groups from a variety of social, cultural, emotional, and educational
backgrounds.
3. Function effectively under stress.
4. Provide client teaching in a variety of modalities including written, oral, and demonstration.
5. Receive instruction verbally, written, and by telephone; interpret and implement.
6. Demonstrate appropriate control of affective behaviors, verbal, physical, and emotional levels to ensure the emotional, physical, mental, and
behavioral safety in compliance with ethical standards of the American Nursing Association.
5GAVILAN NURSING PROGRAM UNIFORM GUIDELINES
Scrub top: Royal blue V-neck
Scrub bottom: Royal blue elastic or drawstring waist
Jacket: White, snap front, no collar
Shoes: White
Examples:
6You are not required to purchase your uniform from these vendors, this is a
recommendation.
7You are not required to complete your livescan here, this is a recommendation.
Livescan Fee is $52.00 cash exact or check for Gavilan C.N.A class
85055 Santa Teresa Blvd • Gilroy • CA • 95020 • (408) 848-4800
FINGERPRINTING/LIVE SCAN REIMBURSEMENT FORM
Student Name: _______________________________________________ G# ______________________________
Last Name First Name M.I.
Student’s Main Phone Number (______) __________________________
**IMPORTANT INFORMATION ABOUT YOUR ADDRESS**
In order to avoid delay, please be sure that the address you include on this form matches the address you
have listed on Self Service Banner. If you need to update your address, please update it online at mygav.com or at
the Admissions and Records Office.
Address: ____________________________________________________________________________________
Street Number Street Name Apt # City State Zip
Live Scan Site: _______________________________________________________________________________
Live Scan Fee: $________________________________ Live Scan Date: ______________________________
ATTACH
ORIGINAL
RECEIPT
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